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RESEARCH ARTICLE

Parenting style and family type, but not child temperament, are associated with television viewing time in children at two years of age Anna S. Howe1☯¤, Anne-Louise M. Heath2‡, Julie Lawrence3‡, Barbara C. Galland3‡, Andrew R. Gray4☯, Barry J. Taylor3‡, Rachel Sayers3‡, Rachael W. Taylor1☯*

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OPEN ACCESS Citation: Howe AS, Heath A-LM, Lawrence J, Galland BC, Gray AR, Taylor BJ, et al. (2017) Parenting style and family type, but not child temperament, are associated with television viewing time in children at two years of age. PLoS ONE 12(12): e0188558. https://doi.org/10.1371/ journal.pone.0188558 Editor: Phil Reed, Swansea University, UNITED KINGDOM Received: June 28, 2016 Accepted: November 7, 2017 Published: December 20, 2017 Copyright: © 2017 Howe et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Data Availability Statement: Data are not available as permission was not obtained from participants for use by anyone outside of the research team. Interested parties can contact the Research Manager at [email protected] to request data access. Funding: The POI study was funded by the Health Research Council of New Zealand (grants 08/374, 12/281 and 12/310) to BJT and RWT. RWT is also supported by the KPS Fellowship in Early

1 Department of Medicine, University of Otago, Dunedin, New Zealand, 2 Department of Human Nutrition, University of Otago, Dunedin, New Zealand, 3 Department of Women’s and Children’s Health, University of Otago, Dunedin, New Zealand, 4 Department of Preventive and Social Medicine, University of Otago, Dunedin, New Zealand ☯ These authors contributed equally to this work. ¤ Current address: Department of General Practice and Primary Healthcare, School of Population Health, University of Auckland, Auckland, New Zealand ‡ These authors also contributed equally to this work. * [email protected]

Abstract Objectives Despite the American Academy of Pediatrics (AAP) recommending that electronic media be avoided in children under two years of age, screen use is common in infants and toddlers. The aims of this study were to determine how parenting style, infant temperament, and family type are associated with television viewing in two-year-old children.

Study design Participants were from the Prevention of Overweight in Infancy (POI) randomized controlled trial (n = 802) (Dunedin, New Zealand). Demographic information was collected at baseline (late pregnancy), and television and other screen time assessed by questionnaire at 24 months of age. Parenting style (Parenting Practices Questionnaire), infant temperament (Colorado Childhood Temperament Inventory), and family type (7 categories) were reported by both parents.

Results Data were available for 487 participants (61% of the original participants). Median television viewing was relatively low at 21 minutes per day, or 30 minutes in those watching television (82%). Children who watched television played with mobile phones (12% of children) or iPads/tablets (22% of children) more frequently than children who did not (6% of children). In terms of parenting style, children of more authoritarian mothers (β = 17, 95% CI: 6–27 minutes), more authoritarian partners (β = 14, 95% CI: 2–26 minutes), or more permissive mothers (β = 10, 95% CI: 3–17 minutes) watched significantly more television. No significant relationships were observed between child temperament and time watching television after

PLOS ONE | https://doi.org/10.1371/journal.pone.0188558 December 20, 2017

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Parenting, temperament, family type and television in children

Childhood Obesity. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

adjustment for confounding variables. Children from “active” families (as rated by partners) watched 29 minutes less television each day (P = 0.002).

Competing interests: The authors have declared that no competing interests exist.

Conclusions Parenting style and family type were associated with television viewing time in young children, whereas child temperament was not.

Introduction Energy-dense foods, low levels of physical activity, and sedentary behaviors (including use of electronic media such as television) have all been implicated in childhood obesity [1, 2]. Independent of obesity, childhood “screen time” is also associated with an increased risk of sleep disturbances [3] and problems with attention [4], and may displace time in other developmentally important activities including reading [5] and creative play [6]. Despite clear recommendations that parents should discourage media use, including television viewing, in children less than two years of age [7, 8], it is clear that many infants and toddlers [9], perhaps as many as 90% [10], are exposed to television and other electronic media. Limited evidence suggests New Zealand toddlers may be watching as little as 1–3 hours per week [11] or as much as 90 minutes per day [12]. Given this high exposure, it is surprising that relatively few studies have examined factors that may predict levels of television viewing in young children [13]. Higher viewing hours have been associated with ethnic minority status, lower levels of maternal education and employment, marital status, and maternal depression in some [10, 14, 15], but not all [16, 17], studies in infants and preschool children. Parenting behaviors, such as allowing a television in the child’s bedroom [18, 19], fewer rules around television use [20], and greater maternal television viewing [17, 21, 22], have also been associated with higher viewing time in children, although these findings have not been unanimous [13]. Investigation of wider issues, including parenting style and family “type”, is warranted given the over-riding influence of the home environment in the early years [23]. In one study, low-income families in which parents valued complete compliance had pre-school children who watched more television [15], but other studies have observed no relationship between parenting style and screen use [19, 22]. Infant temperament may be important if parents of young children with more challenging behaviors use screen time as a distraction [24], for instance, it has been reported that infants whose mothers perceived them to be fussy or cry frequently, were more likely to watch television daily [17]. Both parenting style [25] and ratings of infant temperament [26] can differ between mothers and fathers, yet no studies appear to have evaluated media viewing in young children in relation to these characteristics assessed separately in both parents. Whilst television viewing has previously been the main source of screen use, computers, gaming consoles, smart phones, and tablets are increasingly popular [27]. In particular, the rise of touchscreen devices which are small and relatively easy to use can facilitate engagement by the very young [27]. One survey of infants and toddlers suggests that as many as 50 percent of children under 2 years of age could be allowed to use touch screens by their parents [28]. Some parents believe that touchscreen devices teach the child new skills and knowledge, are fun and entertaining, or occupy the child when the parent needs to do something [28]. However, in children 3–5 years of age, while touchscreen devices were found to be used for


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educational games and apps, traditional television viewing was still more common, making up 60% of the reported viewing time [29]. Concurrent screen use is common in adolescents and young adults, and 40% of pre-schoolers have been found to multitask with screen devices [29]. While the amount of time the children spent using touchscreen devices was positively associated with concurrent screen use, preference for television viewing was unrelated to concurrent device use [29]. Therefore, the aim of this study was to examine the extent to which parenting style, infant temperament, and family type, as estimated separately by mothers and their partners, were associated with screen time in two-year-old children. In addition, it was of interest to us to see what associations might exist between the amount of time a toddler watches television and the use of other media.

Methods These data were obtained from the Prevention of Overweight in Infancy (POI) study, a randomized controlled trial investigating whether extra education and support around food, activity, breastfeeding and sleep reduced rates of excessive weight gain in the first two years of life (clinical trials registration at ClinicalTrials.gov (Clinical Trials NCT00892983)). As a protocol paper has been published [30], only methods relevant to the current study are described briefly here. The New Zealand Lower South Regional Ethics Committee approved the study (LRS/08/12/ 063), and all adult participants gave written informed consent for themselves and their children. A cohort of 802 women were recruited in late pregnancy for the two-year intervention and randomized to one of four groups: 1) control, 2) FAB (food, activity, breastfeeding), 3) Sleep or 4) Combination (both interventions). Those in the FAB and Combination groups received a total of 8–9 contacts, covering a wide range of topics, including education on restricting television (and other media) viewing in children before two years of age. Those in the Sleep (and Combination) groups received an educational programme (2 sessions) discussing normal sleep patterns, safe sleep practices and prevention of sleep problems. All participants received standard government-funded well-child care (http://www.wellchild.org.nz/). There were no significant differences among the intervention groups in the time spent watching television at 24 months [31]. Therefore, data from all four groups were combined in the current analysis, and intervention group was included as a confounder in analyses as described below. Data collected at baseline (third trimester) included estimated maternal pre-pregnancy body mass index (BMI), current estimated paternal BMI, and maternal and partner (all fathers for this sub-study population) age and ethnicity. The level of household deprivation was provided by the New Zealand Deprivation Index (NZDep2006), which ranges from 1 (indicating areas of least deprivation) to 10 (areas of highest deprivation) [32]. Infant birth characteristics (date of birth, weight, gestational age) were collected from hospital records. Maternal depression was assessed using the Edinburgh Postnatal Depression Scale (EPDS) [33], validated for use in the prenatal period [34]. Scores were dichotomized into ‘not depressed’ (< 10), and ‘possibly depressed’ ( 10). Data collected when the children were 24 months of age included anthropometry, parent and child media usage, parenting style, child temperament, family type, and maternal and child physical activity. Weight (WB-100MA, Tanita (kg)) and height (Holtain Model 603VR, Harpenden and Leicester Height Measure Mk II, Invicta (cm)) were measured in duplicate with the subject dressed only in light clothing (diaper and singlet for children, minimal clothing for adults) following standard techniques [35] in both parents and in the child. Child body mass index (BMI) z-score was calculated using World Health Organization growth standards [36]. Mothers reported their own usual screen time (television, computers and tablets, video


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games) in minutes per day. Mothers provided child viewing time (television, DVDs and videos) as both frequency (days per week) and time (usual minutes per day on days watched), from which minutes of viewing per day was calculated (this was the variable used to describe television watching in subsequent hypothesis testing). In addition, mothers provided frequency of child media use (television, DVDs or videos, computer, mobile phone, and tablet use) categorized as: does not use, occasional (up to 2 times per week), regular (3–5 times per week), and daily (every day). Maternal physical activity was assessed using the short form of the New Zealand Physical Activity Questionnaire which is based on the International Physical Activity Questionnaire [37], so that metabolic equivalents (MET) minutes per week could be calculated [38]. Physical activity was assessed in children using Actical accelerometers (MiniMitter Co., Bend, OR) worn over the right hip 24-hours a day for 5–7 days, and expressed as counts per minute once all sleep time had been removed individually from the data using an automated algorithm [39, 40]. Parenting style was assessed in mothers and fathers using a 30-item questionnaire which provided scores for three sub-scales: authoritarian (13-items), authoritative (13-items), and permissive (4-items) parenting, assessed on a six-point scale (never to always) [41]. Dimensions of authoritative parent style were assessed using statements about responsiveness to child’s feelings/needs, encouraging child to speak freely, and treating child as an equal member of family. Dimensions of authoritarian parenting were assessed with statements about reminding the child I am the parent, using threats as a form of punishment, and criticism to improve behaviour, while dimensions of permissive parenting was assessed with statements about finding it difficult to discipline the child, and ignoring bad behaviour. Both parents also completed the 30-item Colorado Childhood Temperament Inventory [42] which yields six sub-scales: sociability (prefers the presence of others to being alone), emotionality (tendency to get easily distressed and upset), activity (activity level), attention span-persistence (distractability), reaction to food (extent to which a new food is taken without fussing), and soothability (ease with which the infant can be calmed when upset). Cronbach’s alpha for all subscales in our study population ranged from 0.98–1.00. Each parent was also asked to indicate the extent to which they felt their family was i) “active or sporty”, ii) “media savvy”, iii) “bookish”, iv) “outdoor people”, v) “musical”, vi) “religious/spiritual”, and vii) “creative or arty” using possible response options of “not really us”, “a little like us”, or “definitely like us”.

Statistical analysis “Minutes of television per day” was used to examine whether children met the 2011 AAP guideline [7]: no television was coded as meeting the guideline, and any minutes of television was coded as not meeting the guideline. While the 2016 AAP guidelines [8] recommend avoiding digital media use for children younger than 18–24 months, we have categorized television use based on the 2011 AAP guidelines of discouraging media use in those younger than 2 years [43]. To compare differences between groups, Chi-square tests or Fisher’s exact test (where more than 20% of cells had expected frequencies below 5) were used for categorical variables with pair-wise comparison undertaken for categorical variables with more than two categories if there was evidence of a significant difference between the categories overall. Mann-Whitney tests were used for continuous or ordinal variables. As the continuous data were non-normally distributed, they are presented as medians with inter-quartile ranges (IQR). Due to the nonnormal distribution of the residuals, quantile regression using the 50th percentile (median) was used to investigate associations between demographic variables and television minutes, and to examine the unadjusted and adjusted associations between independent variables (parenting style, infant temperament, family type) and television minutes. Continuous independent variables were tested for nonlinearity by adding a quadratic term (none were significant). Quantile


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regression models were adjusted for intervention group, demographic variables from the unadjusted models that had P 0.25, and household deprivation and maternal parity (stratification variables used when randomizing participants to the POI study groups). Although children’s physical activity reached the statistical threshold for inclusion in the models, it was not included in the fully adjusted models because the limited number of children with accelerometry data would have reduced the number of participants available for the analysis. Investigation into the missing data indicated that those with missing data did not differ with those who had complete data in respect to demographic variables. Some missingness was due to erroneous data discovered during data cleaning, and some was because some participants refused to take part in the collection of the physical activity data. These missing data were not imputed because imputing data ‘missing not at random’ can introduce more bias when using multiple imputation than complete case analysis [44]. Wald tests were used to determine the overall effect for categorical variables in the regression models, with pairwise comparisons between different levels of the variable conducted for categorical variables with more than two categories if there was evidence of a significant difference between the categories overall. The effect sizes for quantile regression models are the predicted change (95% CI) to median minutes of children’s television viewing per day for every unit change in the independent variable, or between reference and non-reference levels of categorical variables. Two-sided P-values less than 0.05 were considered statistically significant. All statistical analyses were conducted using Stata 12.1 (StataCorp, College Station, TX, USA).

Results At 24 months of age, 686 participants remained in the POI study (86%), although only 487 families provided questionnaire data (61% of the original participants) (Fig 1). Table 1 demonstrates that the only differences between participants who had usable data and those who did not were: maternal and partner age (those with useable data were older), and partner ethnicity (those with useable data were more likely to be New Zealand European). Minutes of television watched did not differ between the four study groups and ranged from 0 (18% of children) to 120 minutes per day, with median (IQR) viewing of 21 (IQR 54) minutes per day in the total sample (Table 1), and 30 (IQR 46) minutes in those who watched television. In our sample, most children watched DVDs or videos (75%), television (76%) and played games on computers and gaming consoles (73%) at least once a week, and a number of children were using mobile phones (17%), and tablets (18%). (Table 2). Not surprisingly, children who did not meet the AAP 2011 television guideline [7] (18%) used all forms of device more frequently than children who met the guidelines. Unadjusted models found higher maternal pre-pregnancy BMI (1 minute per unit BMI, P = 0.013) and maternal screen time (6 minutes per hour of maternal screen time, P < 0.001) were positively associated with child television viewing time. Mothers depressed in pregnancy had children who watched an extra 11 minutes of TV per day compared to children of nondepressed mothers (P = 0.030). Child’s physical activity (P = 0.014) was negatively associated with children’s viewing time (Table 3). There were significant associations between authoritative, authoritarian, and permissive parenting styles and child television viewing in the unadjusted models (Table 4). However, only the positive association between the mother having an authoritarian or permissive style, and the partner having an authoritarian style, remained statistically significantly associated with minutes of television watching in adjusted models (Table 4). In the current sample, mothers (and partners) with the more authoritarian parenting style had children who watched a median of 17 (and 14) extra minutes of television per day compared to children with less


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Fig 1. Flow of POI study participants through to 24 months of age. https://doi.org/10.1371/journal.pone.0188558.g001


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Table 1. Characteristics of the study sample at baseline (n = 802). Did provide data (n = 487)

Did not provide data (n = 315)

n (%)

n (%)

Female

230 (47%)

161 (51%)

Male

257 (53%)

154 (49%)

385 (79%)

240 (76%)

Māori

43 (9%)

32 (10%)

Other

59 (12%)

43 (14%)

424 (87%)

258 (82%)

Māori

22 (5%)

24 (8%)

Other

41 (8%)

33 (10%)

337 (69%)

149 (47%)

Māori

24 (5%)

12 (4%)

0.490

Other

126 (26%)

154 (49%)